Mansfield Referral Association Member Application

To apply, please complete and submit this application in full.

Personal Information

_{Fields marked with an * are required}

First Name *

Last Name *

Business Phone*

Cell Phone*

E-mail Address *

How did you hear about us?*

Business Information

Business Name*

Business Address (please enter website if there is no physical address)

City

State

Zip Code

Website

Tell us about your business*

Education and Certifications

Years in the Company*

Years in the Industry*

Years the company has been in business*

Is this business your full-time career?*

YesNo

If applicable, do you have workman's compensation or general liability insurance?*

YesNoN/A

Association Information

Do you belong to any other networking associations?*

YesNo

If so, please list association names

Why would you like to join MRA?*

Personal References

First Name *

Last Name *

Phone Number*

Relationship*

E-mail Address *

Professional References

Reference 1:

First Name *

Last Name *

Business Name*

Position Title*

Phone Number*

Relationship*

E-mail Address *

Reference 2:

First Name *

Last Name *

Business Name*

Position Title*

Phone Number*

Relationship*

E-mail Address *

Terms & Conditions

I agree to abide by the rules & regulations established by MRA leadership
I agree to regularly contribute business referrals and ideas to each member of the group
I agree to attend and arrive on time each week to meetings
I agree not to miss more than 5 meetings in 6 months
I agree to send a substitute in my absence if unable to attend a meeting
I affirm that I represent my primary, full-time occupation
I agree to remain current with my membership dues
I affirm that I am not part of any organization or type of business that conflicts with MRA

Please bring a check for $160 to the next meeting for first quarter dues.

By checking this box, I affirm that I have read and will abide by the rules of this association listed above.

Signature*

Date (MM/DD?YYYY)*

Thank You!

We have received your request and will get back to you soon.

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